Risky Sexual Behaviours - RCSI MED Year 2

• REGU covers Risky Sexual Behaviours at the RCSI
• The lecturer is Ms Luma Bashmi, email [email protected]
• The course is for MED Year 2, School of Medicine 2023/2024

Learning Outcomes

• Define what constitutes sexual health
• Identify the influence of behavior on sexual health and risky sexual behavior
• Summarize research on sexual behavior and its role in managing STIs and HIV
• Learn how to take a sexual history
• Integrate behavior change theories to promote positive sexual health

Defining Sexual Health

• Sexual health includes physical, emotional, mental, and social well-being related to sexuality
• It's more than just the absence of disease or dysfunction
• Requires a positive, respectful approach to sexuality and sexual relationships
• Encompasses the possibility of pleasurable and safe sexual experiences, free from coercion, discrimination, and violence

Sexuality

• A central aspect of being human throughout life
• Sexuality incorporates biological sex, gender identities, sexual orientation, eroticism, pleasure, intimacy, and reproduction.
• Expressed through desires, attitudes, values, behaviors, and relationships.
• Influenced by biological, social, economic, political, cultural, ethical, legal, historical, and religious factors

Sexual Pleasure

• Sexual pleasure, as defined by the World Association for Sexual Health (WAS, 2021),
• Includes the physical and/or psychological satisfaction and enjoyment derived from shared or solitary erotic experiences, including thoughts, fantasies, dreams, emotions, and feelings.

Core Elements of Sexual Health

• Elements from a public health perspective include:
• STIs (including HIV) and reproductive tract infections
• Unintended pregnancy and safe abortions
• Sexual dysfunction and infertility
• Violence related to gender and sexuality (including FGM)
• Sexual health and education for young people
• Sexual orientation and gender identity
• Mental health issues
• Impact of physical disabilities and chronic illnesses
• Promotion of safe and satisfying sexual experiences

Sexual Health and Healthcare Practice Factors:

• Fertility management (contraception and infertility)
• Sexually transmitted infections (STIs), including HIV/AIDS
• Intrinsically related to behavior such as contraception and protection

Examples of High-Risk Sexual Behaviors

• Unprotected intercourse: Without male or female condom use, except in a long-term, single-partner (monogamous) relationship
• Unprotected mouth-to-genital contact
• Early sexual activity: Especially before age 18
• Having multiple sex partners
• Having a high-risk partner: Someone who has multiple sex partners or other risk factors
• Engaging in sex with a partner who injects drugs
• Exchanging sex (sex work) for drugs or money

HIV in Ireland 2023

• 911 total diagnoses in 2023
  • 19% (n=173) were first-time diagnoses
  • 61% (n=553) were previously positive
  • 20% (n=185) were unknown
• The rate of total diagnoses increased in recent years
• Previous positives accounted for the majority of diagnoses with a large increase in 2022 and 2023

HIV diagnoses by probable route of transmission

• In 2023:
  • 39% heterosexuals
  • 34% gbMSM
  • 3% PWID
  • 24% unknown/other
• gbMSM accounted for the highest proportion from 2012-2022

HIV Rates by Gender and Age Group (2023)

• 78% were aged 25-49 years
• 5% were aged 15-24 years
• 16% were aged 50+ years
• In all age groups except those aged 45-49 years, the rate was higher in males
• The rate was highest among males aged 30-34 years
• The rate was highest among females aged 40-44 years

STIs in Ireland (2023)

• Common STIs include:
• Chlamydia with 13,711 notifications in 2023
• Gonorrhoea with 6,824 notifications
• Herpes simplex with (genital) 1,687 notifications
• There were no notifications of chancroid or granuloma inguinale for 2023
• Total number of STIs are underestimated, data on AGW and NSU were unavailable

STIs by Age and Gender (2023)

• Notification rates are highest in males and females aged 20-24 years
• STI notification rates peak in females aged 20-24 years
• STI notification rates in males remain high in the following age groups;
• 20-24 years
• 25-29 years
• 30-34 years

STIs in the Middle East

• Obeid et al., 2024:
• Most reported STIs were chlamydia (n = 17), HPV (n = 14), and NG (n = 11)
• Clinical population: HPV (n = 51), HBV (n = 31), and HCV (n = 18) were the most common STIs in High risk cohorts: HIV (n = 31) and HPV (n = 20) were most frequently reported.
• Saudi Arabia (Banghali, 2020):
• Between 2005 - 2012 there were 68,886 new cases of STDs
• 14.3% AIDS (n = 9843, ~ average of 1406 new cases per year) of all cases
• Most common STIs: Non-gonococcal urethritis (51.7%); trichomoniasis (18.4%), gonococcal urethritis (4.4%), syphilis (2.6%), genital warts (5.8%), genital herpes (2.2%), and chancroid (0.7%).

Sexual Behavior in Palestinian Youth (17+ Yrs Old)

• Reported any sexual experience:
• 25% of older (19-24) unmarried male youth and 22% of younger (17-18) male youth report similar rates of those identifying as female
• Phone sex (sexting) and internet sex involving another person:
• 38% of older and 33% of younger (age 18-19) report having ever engaged in this activity
• 30% of older female youth and 23% of those 18 and 19 report having done so

Pregnancy as a Sexual Health Challenge

• 38% of all pregnancies are unplanned
• 22% of all pregnancies are terminated
• "Unplanned vs unwanted" many unplanned become wanted outcomes
• Societies are most concerned with:
• Teenage pregnancy (pregnancy in older age?)
• Pregnancy outside marriage
• Pregnancy in high risk groups (HIV+ve, substance users)

Crisis or Unplanned Pregnancy

• Unwanted at the time of pregnancy or becoming unwanted during pregnancy
• In Ireland 12% of all pregnancies are considered a crisis, 1 in 10
• Outcomes show:
  • Live birth with the mother keeping baby 76%
  • Abortion 15%
  • Miscarriage or stillbirth 8%
  • Adoption <1%

Summarizing Sexual Behaviour Research

• 20th century focus on sex as behaviour and not just outcomes
• Defining moments
• The Kinsey Report in 1948 looked at white americans, population patterns and variety of sexual behavior with a sex as a natural healthy drive view
• Masters & Johnson in the 1960s looked at heterosexual americans, laboratory studies of sexual responses with a how to measure/improve sex with understanding physiology view
• The Hite Reports in the 1970s & 1980s looked at population/lab studies of sexuality and pleasure with the understanding pleasure - gender differences view

National Studies of Sexual Behavior

• National sexual behaviour surveys exist in the US, Australia, and the UK in the 1990s
• The main impetus in many countries was concerns about HIV
• Irelands first national study 2006 surveyed >7,000 adults
• Completed by RCSI, with ISSHR: Irish Study of Sexual Health & Relationships
• Aim of such studies has been health policy, public and professional education campaigns and plans for delivering services

Health Policy Examples

• Screen for HIV in pregnant women such as screen for Chlamydia in young people, the latter not done in Ireland
• Public and professional education campaigns such as information in TV and schools
• Plans for delivering services such as a plan for emergency contraception that is provided over-the-counter or doctors precription

Changes in Sexual Health Policies

• HSE-SHCPP responsible for the implementation of the National Sexual Health Strategy 2015-2020
• Significant developments related to:
• New health policy publication and implementation (e.g. Healthy Ireland Framework 2013-2015; recommendations for the Joint Oireachtas Committee on the 8th amendment;Sláintecare Implementation Strategy, 2019)
• Legislative and constitutional changes (e.g. changes to legal status of same-sex relationships, transgender identification and access to abortion services)
• And drug licensing changes (e.g. introduction of PrEP for HIV prevention and increased access to emergency hormonal contraception)

Access to Contraception

• Introduced in 2022 in Ireland, now extended to 35-year olds
• To access one must: be a woman or person with a uterus, 17 to 35 years of age, living in Ireland and have a PPS number
• Scope of cover: GP or doctor’s appointments, prescriptions from your doctor, approved products free of charge at participating pharmacies, certain fittings and removals of implants and IUDs or IUSs, any check-ups and other follow up, relating to an implant or coil and emergency contraception

Impact of PrEP on HIV Outcomes

• Declining rate of HIV among gbMSM since peak in 2015 (-56%)
• PrEP was introduced as policy for people at risk of sexual acquisition of HIV in Nov 2019

Unplanned Pregnancy and Abortion Facts

• Abortion is legal up until 12 weeks gestation since January 2019 in Ireland
• In 2018 there were almost 2879 Irish abortions in the UK reduced from 3019 in 2017
• In 2001 the number was 6673 showing a decrease of 43%
• Medical and psychological aftercare for these women is a challenge in Ireland

Taking a Sexual History Tips:

• It is important to clarify your values around sexual practices
• Many practitioners do not feel entirely comfortable asking detailed questions
• Many practitioners also have biases and pre conceived beliefs
• Patients' primary barrier to discussing sexual health is physician discomfort and anticipated non-empathetic response.
• This is particularly true for LGBT patients, where providers often feel ill-prepared to discuss intimate issues, or feel uncomfortable doing so.

Screening Questions Should:

• Avoiding moral or religious judgement of the patient's behavior
• Avoid terms that make assumptions about sexual behavior or orientation
• Use "how many partners you have had in the past year, rather than are you monogamous?"
• Ensure shared understanding of terminology and pronunciation
• To avoid confusion if the patient provides a slang term for their anatomy, gently connect the slang word to the medical terminology.
• Establish rapport and consent before addressing sensitive topics
• Respect the patient's right to decline answering questions or sharing information
• Use a sensitive tone that normalizes the topics you are discussing
• Use neutral and inclusive terms that avoid assumptions about orientation

PLISSIT Model

• Creating space for someone to discuss sexual health

• Using questions like "Is there anything about your sexual health you'd like to discuss?"

• Suggesting targeted options and causes for any identified symptoms

• Help with a diagnosis and how to manage and address the identified issue

• Referrals can be made to sexual health specialist such as a sex therapist

In Practice Example

• An example of putting the model in practice is the use of the following phrases
• Permission - "Do you feel comfortable talking about your sexuality?"
• Limited information - “I have a brochure that may help you understand your situation better.”
• Specfic Suggestions - "Have you attempted different positions to relieve your arthritis pain?"
• Intensive Therapy- "I know a specialist that I can refer you to that can better meet your needs."

Promoting Behavior Change

• Common Challenges: inconsistent users v infrequent users
• Strategies: create consistent action that helps users

Attitude change and beliefs

• HEALTH BELIEF MODEL

• Susceptibility - promote awareness that the person is susceptible to risks

• Severity - seriousness of unwanted pregnancy, HIV, chlamydia

• Action - condoms = safer sex

• Barriers - make contraceptives available, overcome stigma, make planning the smart choice

• THEORY OF PLANNED BEHAVIOUR

• Intention - carrying condoms

• Perceived behavioural control - knowing how/when to raise subject of condoms

• Social norms - what is expected/acceptable